Chinese and Western medicine diagnosis and treatment of shock
I. Overview
Shock refers to the acute circulatory failure caused by a variety of strong pathogenic factors acting on the body, and is characterized by the progressive development of the pathophysiological process of ischemia and hypoxia of vital organs or impaired utilization of tissue oxygen and nutrients, resulting in inadequate microcirculatory perfusion, impaired cellular metabolism and impaired function as the main manifestation of the clinical syndrome. Shock is often divided into five categories: hypovolemic shock, infectious shock, cardiogenic shock, neurogenic shock, and anaphylactic shock. Clinically, traumatic shock and hemorrhagic shock are often classified as hypovolemic shock, while hypovolemic and infectious shock are most common in surgery.
Shock can be divided into pre-shock and shock phase (shock suppression phase) according to the pathogenesis, and the latter can be divided into shock compensation phase (phase I, early shock phase), shock progression phase (phase II, mid shock phase), and shock refractory phase (phase III, late shock phase).
There are many causes of shock, and most of the shock is caused by multiple etiologies. If in the early stage of shock, effective measures can be taken in time to restore tissue perfusion as soon as possible, shock can be prevented; if the metabolic disorders that have occurred are not corrected in time, resulting in extensive cell damage, it can lead to multi-organ insufficiency (MODS) or even multi-organ failure (MOF), and eventually develop into irreversible shock and life-threatening.
With the onset and progression of shock, the direct consequence of insufficient tissue perfusion is tissue hypoxia. Therefore, restoring the oxygen supply to tissue cells, promoting the effective use of oxygen, re-establishing the balance of oxygen supply and demand and maintaining normal cellular function are the key aspects of the treatment of shock.
Shock belongs to the “syncope evidence” in TCM, which refers to a type of illness caused by internal trapping of evil toxins, or internal injury to dirty qi, or loss of essence and blood, resulting in the reversal of qi and blood and depletion of positive qi. The clinical manifestations of syncope, syncope and corporeal syncope due to blood loss, asthma, death of yin, death of yang and external evil are similar to those of shock.
Diagnostic criteria and differentiation of symptoms in traditional Chinese medicine
(A) Diagnostic criteria
The main clinical manifestations of all types of shock are hypotension, poor microcirculatory perfusion, sympathetic hyperactivity, etc. The diagnostic criteria for shock formulated at the National Conference on Acute Triple Failure in February 1982 are as follows
(1) There is an etiology that induces shock.
② Abnormal consciousness.
③Pulse count, <100 times/minute or not palpable.
④Inadequate perfusion of the peripheral circulation: wet and cold extremities, positive skin acupressure at the sternal area (refill after pressure >2 seconds), skin pattern, pale or cyanotic mucous membranes, etc.; urine output <30 ml/h or urinary closure.
⑤Systolic blood pressure <80mmHg.
⑥Pulse pressure <20mmHg.
(7) In case of pre-existing hypertension, the systolic blood pressure is 30% lower than the original level.
Anyone who meets the above item ①, and two of items ②, ③, ④ and one of items ⑤, ⑥, ⑦, can be diagnosed as shock.
(B) Differentiation of the symptoms
1.Syncope
Syncope is a sudden and brief loss of consciousness caused by insufficient blood supply to the brain and temporary lack of oxygen. The syncope period is usually a few seconds to a few minutes, if the loss of consciousness for a long time, the phenomenon of twitching of the limbs may occur. After the patient regains consciousness, he or she is still pale, weak, reluctant to speak or move, or has nausea, yawning, hyperventilation, bradycardia, headache, etc.
2.Convulsion evidence
The syncope attack is characterized by pale face and cold extremities, which can be gradually awakened within a short period of time without hemiplegia, aphasia, and distorted speech; while the coma has a heavy onset, lasts longer, and is not easily awakened within a short period of time, and often has symptoms related to the original disease or hemiplegia and unfavorable speech after awakening, which can be distinguished.
Western medical diagnostic criteria and differential diagnosis
(A) Diagnostic criteria
1. Medical history
There are various primary diseases that cause the occurrence of shock.
2.Clinical manifestations
(1) Mental status: reflect the blood perfusion of brain tissue and systemic circulatory status. If the mental state is clear, it means that the circulating blood volume is sufficient; if the expression is indifferent, restless, delirious or drowsy, coma, it reflects insufficient effective circulating blood volume and brain dysfunction.
(2) Skin temperature and color: It is a sign of the perfusion condition of the body surface. If the patient’s extremities are warm, dry skin, light pressure on the nails or lips, local temporary ischemia pale, after relaxation, the color quickly turns to normal, indicating that the peripheral circulation has been restored, the shock is better; vice versa, it indicates that the shock situation still exists.
(3) blood pressure: maintain a stable blood pressure is very important in the treatment of shock. It should be measured and compared regularly. However, blood pressure is not the most sensitive indicator to reflect the degree of shock. When judging the condition, a comprehensive analysis should also be performed.
(4) Urine volume: It is a valid indicator to reflect the renal blood perfusion. Catheterization should be left in place and hourly urine volume should be observed and recorded. Low urine is usually a sign of early shock and incomplete recovery from shock. Urine volume <25ml/h and increased specific gravity indicate that blood volume is still insufficient; those with normal blood pressure but still low urine volume and low specific gravity should promptly review renal function and be alert to acute renal failure. When the urine volume is maintained above 30ml/h, it means that the blood volume is sufficient and the renal perfusion is back to normal. However, clinical attention should be paid to the obvious diuretic effect when hypertonic solution is used in trauma critically ill patients; the phenomenon of urinary collapse can occur in those with cranial injury affecting the posterior pituitary gland; those with urinary tract injury can also show oliguria and anuria.
(5) The corresponding performance of different periods of shock.
① Shock compensation period (stage I, early shock): the skin can be seen wet and cold, cyanosis and pallor, slow recovery of skin color when pressing the skin, subcutaneous green-blue reticular streaks can be seen, often accompanied by rapid heartbeat and respiration, reduced urine output and other symptoms. The patient’s blood pressure is mostly in the normal range, and many symptoms are often not obvious, which should be taken seriously.
② Progressive phase of shock (phase II, mid-stage of shock): also known as reversible decompensation phase. The main manifestations are progressive drop in blood pressure, oliguria or even anuria, cold, cyanotic or even florid skin. Cardiac and cerebral dysfunction may occur, with weakness of the cardiac wave, apathy, drowsiness or even coma.
③ Shock refractory stage (stage III, late shock stage): also called irreversible decompensation stage. The main manifestation is a significant drop in blood pressure, and it is still difficult to recover with blood pressure-raising drugs. The pulse rate is fine, the central venous pressure is reduced, the veins collapse, and circulatory failure occurs. Due to the aggravation of microcirculatory stasis induced diffuse intravascular coagulation (DIC), the systemic microcirculatory perfusion is seriously inadequate, cell metabolism is impaired until death, and multiple organs such as heart, brain, lung and kidney become dysfunctional or even fail, and the mortality rate is extremely high.
3.Special indicators monitoring
(1) Central venous pressure (CVP) measurement: reflects the change of pressure in the right atrium or vena cava of the thoracic cavity. the normal value of CVP is 6-12 cmH20. when CVP<5cmH20, it indicates insufficient blood volume; when CVP>15cmH20, it indicates cardiac insufficiency, excessive constriction of venous vascular bed or increased resistance of pulmonary circulation; when CVP>20cmH20, it indicates the presence of congestive heart failure.
(2) Pulmonary capillary wedge pressure (PCWP) measurement: reflects pulmonary venous, left atrial and left ventricular pressures, and can be monitored with Swan-Ganz float catheter. lower than normal PCWP reflects hypovolemia (more sensitive than CVP); higher PCWP is commonly associated with increased pulmonary circulatory resistance, such as in pulmonary edema.
(3) Arterial blood gas analysis: dynamic monitoring helps to understand the acid-base balance in shock.
(4) Cardiac output (CO) and cardiac index (CI): It is important to detect and adjust abnormal hemodynamics in time when resuscitating shock.
(5) Shock index (SI): is the ratio of pulse rate (times/min) to systolic blood pressure (mmHg), is one of the clinical indicators reflecting hemodynamics, can be used to roughly estimate the amount of blood loss and the degree of shock classification. The normal value of this index is 0.5~0.7. If the blood loss is less than 1/4 of the circulating blood volume, SI <1; if the blood loss is 1/4~1/3 of the circulating blood volume, SI ≈1; if the blood loss is >1/3 of the circulating blood volume, SI >1. In other words, if SI=1, the blood volume is reduced by 10%~30%, which is mild shock; if SI=1.5, the blood volume is reduced by 30%~50%, which is moderate shock; if SI=1.5, the blood volume is reduced by 30%~50%, which is moderate shock; if SI=1.5, the blood volume is reduced by 30%~50%, which is moderate shock. When SI=1.5, it means blood volume is reduced by 30% to 50%, which is moderate shock; and when SI=2, it means blood volume is reduced by 50% to 70%, which is severe shock.
(6) Detection of DIC: In patients suspected of having D1C, the quantity and quality of platelets, the degree of depletion of coagulation factors and a number of indicators reflecting fibrinolytic activity should be measured.
(7) Arterial blood lactate determination: It helps to assess the trend of shock and resuscitation.
(B) Differential diagnosis
1, the differential diagnosis of cardiogenic shock: cardiogenic shock is most commonly associated with acute myocardial infarction, according to the clinical manifestations, electrocardiographic changes, blood cardiac enzymes and myoglobin findings, can be confirmed. However, it needs to be differentiated from the following.
①Acute massive pulmonary artery embolism.
②Acute pericardial tamponade.
(iii) Separation of aortic coarctation.
④Tachyarrhythmia.
⑤ Acute aortic valve or mitral valve insufficiency.
2, the differential diagnosis of hypovolemic shock: acute shock due to reduced blood volume should be distinguished from the following.
① Bleeding. Bleeding from the gastrointestinal tract, respiratory tract, urinary tract, genital tract, and finally discharged out of the body is not difficult to diagnose. Splenic rupture, liver rupture, ectopic pregnancy rupture, aortic aneurysm rupture, tumor rupture, etc., bleeding in the abdominal or thoracic cavity, which is not easy to be detected. At this time, in addition to the clinical manifestations of shock, the patient is obviously anemic, with signs of chest and abdominal pain and blood accumulation in the chest and abdominal cavity, and thoracic, abdominal or posterior vaginal fornix aspiration helps to make the diagnosis.
②Surgical trauma. Diagnosis is generally not difficult with a history of trauma and surgical procedures.
③Diabetic ketoacidosis or non-ketotic hyperosmolar coma.
④Acute hemorrhagic pancreatitis.
3, the differential diagnosis of infectious shock: a variety of serious infections may cause shock, the common ones are.
① toxic bacterial dysentery. Most often seen in children, shock may appear before the intestinal symptoms, anal swabs are needed to take stool examination and culture to confirm the diagnosis.
(ii) S. pneumoniae pneumonia. Shock may also occur prior to the onset of respiratory symptoms. Diagnosis needs to be confirmed by chest signs and chest X-ray.
③Epidemic hemorrhagic fever. It is an important disease causing infectious shock.
(iv) Fulminant meningococcal septicemia. It is more common in children, and severe shock is one of the features of this disease.
⑤ Toxic shock syndrome. It is caused by staphylococcal infection, mostly seen in young women who use vaginal plugs during menstruation, resulting in staphylococcal multiplication and toxin absorption; also seen in children with skin and soft tissue staphylococcal infections. Clinical manifestations are high fever, vomiting, headache, sore throat, myalgia, scarlet fever-like rash, watery diarrhea and shock.
IV. Chinese medicine treatment
(A) First-aid treatment
1. Traditional Chinese medicine
(1) Returning Yang to save the rebellion, benefiting Qi and fixing the deficiency: first use 20ml of ginseng injection, add 50% glucose in 40ml and push slowly intravenously, then add 50ml~100ml to 5%~10% glucose in 100ml~250ml and inject rapidly once a day;
(2) Nourishing Yin and promoting fluid, benefiting Qi and fixing detoxification: first use 20ml of Shengve injection, push slowly intravenously, then add 50ml-100ml to 5%-10% glucose or 0.9% saline in 100ml-250ml and drip intravenously;
(3) Promote blood circulation, resolve blood stasis, promote qi flow and relieve pain: 50ml~100ml of Blood BJ injection (the main ingredients are red peony, Chuanxiong, Salvia, safflower and angelica, etc.) is added into 100ml of 0.9% sodium chloride injection intravenously once a day for 7 days. Pharmacological studies have shown that hebepin injection can antagonize endotoxin and inhibit inflammatory mediators, regulate immune response, improve microcirculation, protect endothelial cells, and block abnormal coagulation process.
2.Tested formula
(1) Warming Yang and consolidating detachment: use Ginseng and Longmu Tang or Hui Yang Returning to the Origin Tang.
(2) Clearing the Ying and cooling the Blood: use Qing Ying Tang or Rhizoma Dihuang Tang.
(3) Clearing heat and invigorating the Blood: choose Xianfang Livestrong Drink.
(4) Clearing heat and detoxifying the Blood: Huang Lian Detoxification Tang or Pu Ji Disinfection Drink can be used.
(5) Enlightening the body and awakening the mind: available with the adult medicines Angong Niuhuang Wan and Zixue Dan.
(6) Passing heat from the abdomen: use Rhubarb & Radix Soup or Zengliang Chengqi Tang.
(2) Identification and treatment
1.Qi desquamation evidence
(1) Symptoms: pale face, profuse sweating, depression, shortness of breath, eyes closed and mouth open, and self-induced loss of bowel movements. The tongue is light and fat, and the pulse is fine and weak.
(2) Treatment: Benefit Qi and consolidate deficiency.
(3) Formulation: Doshen Tang or Ginseng and Longmu Tang.
(4) Drug: Ginseng 10g Radix et Rhizoma Polygonatum 10g Dragon Bone 30g Oyster 30g
(5) Add and subtract: If sweating profusely, unheated limbs, palpitations, add Astragalus 30-60g, Medlar 10g, Wu Wei Zi 15g, Calcined Long Mu 30g each; if diarrhea and dysentery with clearing of the grain is more than enough, cold form and limbs, add Akebia 20g, Ginger 10g, Japonica rice 15g, Nutmeg 15g, Wu Wei Zi 10g; if appearing in the late stage of external fever, and also see S in the hands and feet, with a vivid tongue and little fur, and the desire to detach from time to time. Add 15g of Radix Paeoniae Alba, 10g of Colla Corii Asini (molten), 10g of Turtle Board, 20g of Radix Rehmanniae, 10g of Medlar, l0g of Turtle Nail, 6g of Fructus Schisandrae; if women have more than one hemorrhage, add 30g of Radix Astragali, 10g of Fructus Schisandrae, 5g of Panax Ginseng (powdered), 10g of Colla Corii Asini (molten); if the stroke is internally closed and externally removed, accompanied by sudden fainting, pale face, boiling mouth and eyes, 3g of Astragalus, 3g of Radix Sanguisorba, 3g of Radix Aconiti, 3g of Radix Sanguisorbae, 3g of Radix Sanguisorbae. 3g of Radix Aconiti, 3g of Sheng Chuan Wu, 10g of Moutong.
2. Blood loss evidence
(1) Symptoms: pale face, dizziness, dizziness, palpitation, short breath, cold limbs, or even fainting and unconsciousness. The tongue is pale white, the pulse is hollow or the pulse is weak and wants to die, etc.
(2) Treatment: Tonifying Qi and regenerating Blood, cultivating the root and consolidating detachment.
(3) Formula: Angelica Sinensis Tonic Blood Soup combined with Ginseng and Radix Soup.
(4) Drugs: Astragalus membranaceus 60g, Angelica sinensis 10g, Ginseng 10g, Radix et Rhizoma Polygonati (first decoction) 10g.
(5) Add and subtract: add Aconite and Xianhecao as appropriate; also use Add and Subtract Four Things Tang; if due to acute massive bleeding, use Doujian Tang and Ginseng and Radix Soup; if the extremities are cold, add Gui Zhi and Hosanna.
3.Yin loss evidence
(1) Symptoms: flushed face, hot sweat, thirst for cold drinks, shortness of breath, restlessness, delirium, or even coma, wrinkled skin, dry lips and teeth, short urine and red. The tongue is dry and red, and the pulse is thin and weak.
(2) Treatment: Nourish yin and increase fluid, nourish yin and consolidate detachment.
(3) Formulation: Shengve San.
(4) Drug: Ginseng 10g, Mai Dong 10g, Wu Wei Zi 15g
(5) Addition and subtraction: If high fever and profuse sweating persist, add Calcined Longmu 30g each to control sweating and calm the mind; if mental agitation or delirium, add Zixue Dan; if high fever and agitation, dry stools, it is advisable to urgently lower Cunyin and add Chengqi Tang; if vomiting persists, add Fa Xianxia 5g, Dendrobium 10g, Zhi Mu 10g, Zhu Ru 10g to produce fluid and nourish the stomach, subdue rebellion and stop vomiting; if hemorrhage, add Dou Shen Tang to benefit Qi If yin loss affects yang and yin and yang are both lost, there is delirium, dullness of the mouth and eyes, dilated pupils, phlegm in the throat, shortness of breath, sweating like oil, cold extremities, incontinence of the bowels, pale tongue, and weak pulse, then add Ginseng and Radix Soup or Si Wei Tang to urgently restore yang while rescuing yin.
4.Yang loss evidence
(1) Symptoms: pale face, dripping sweat, cold fear, cold limbs, weak respiration, urine and drowning, tiredness and fatigue, or mental confusion, pale tongue, weak pulse.
(2) Treatment: Benefit Qi and return Yang, save the rebellion and fix the detachment.
(3) Formulas: Doujian Tang or Hui Yang Returning to the Essence Tang.
(4) Drugs: Ginseng 10g Radix et Rhizoma Pseudostellariae (first decoction) 10g Dried ginger 10g Mai Dong 10g Wu Wei Zi 15g Chen Pi 10g Licorice 5g.
(5) Addition and subtraction: for those who sweat more than once, add 30g each of Calcined Longmu, or 20g of Cornu Cervi Pantotrichum and 15g of Wuweizi to control sweating and consolidate detachment; after the return of Yang, if the patient is suffering from redness and coldness of the face and feet, with a weak or floating pulse without root, this is a sign of true Yin deficiency and floating deficiency of Yang, so we can use Dihuang Drink to steadily replenish true Yin and warm up to support Yang.
(C) Acupuncture and other therapies
1, body acupuncture: take Renzhong, Susu, Neiguan, Yongquan and other points. Renzhong and Su s are acupoints of the Governor’s Vessel, which can invigorate yang energy to fix the off, and have the function of awakening the mind and opening the orifices, and relieving heat and convulsions. Both points are used for one minute with heavy bird technique; Neiguan has the effect of regulating blood, calming the heart and tranquilizing the mind, and Yongquan also has the effect of opening the orifices and reverting the syncope, and both points can be used for one minute with twisting or lifting and inserting the diarrhea method. Every 30 minutes, the needle can be applied once.
2, moxibustion method: Shen Que, Guan Yuan, Yong Quan, Foot San Li. Shen Que and Guan Yuan can be moxibustion with salt or ginger, and Foot San Li and Yong Quan can be moxibustion with warm needles. 2 to 3 times a day.
3, bloodletting therapy: ten Xuan or twelve well acupuncture points with trigeminal needles to release blood, each point to release 5-8 drops of blood, in order to diarrhea heat and open the orifice, especially for the type of heat toxicity incandescence. The main piercing of the small loop of the transverse veins, so that it bleeds 5 to 8 drops, with the function of relieving heat and relieving spasm.
The actual fact is that you can find a lot of people who have been in the business for a long time. The actual fact is that it is a good idea to have the ability to clear the heat, resuscitate, and return the syncope.
5, take sneeze method: available convulsive nasal san (fine spice, soap horn, half of the summer together with fine powder) frequently to the nose, so that the patient take sneeze to wake up the soul back to sue. Then use Yu Shu Wan (mushroom, with the seeds, halberd, musk, waist yellow, vermilion, five times the seeds) in a pipe and light it, nasal inhalation to take sneeze, can remove the obscenity, open the diaphragm, lower the rebellion.
V. Western medicine treatment
The purpose of treatment is to improve the perfusion of the whole body tissues, restore and maintain the patient’s normal metabolism and organ function, rather than simply raising blood pressure, because blood pressure only represents the relationship between cardiac blood displacement and vascular tone, but does not reflect the cardiac blood displacement and tissue perfusion. The earlier the treatment starts, the better, and timely intervention should be made at the early stage of shock to try to avoid the development of shock to the late stage; for different types of shock, corresponding treatment should be given at different stages; changes in the patient’s condition should be closely observed, with special attention to the central nervous system, heart, lung and kidney function status, and the condition should be evaluated in a timely manner to seize the main contradictions at each stage and adjust the treatment plan at any time; at the same time, the primary disease should be actively treated.
(I) General emergency treatment
1, bed rest, take a flat position with legs elevated 30 °, such as cardiogenic shock with heart failure, should use a semi-recumbent position. Pay attention to keep warm and keep the environment quiet.
2.Continue to administer oxygen and keep the airway open.
3.Establish at least two effective intravenous channels.
4.Observe the hourly urine volume: until the urine volume exceeds 20-30ml/h.
5.Observe peripheral vascular perfusion: good peripheral perfusion indicates normal peripheral vascular resistance. However, the skin vasoconstriction status only suggests changes in peripheral resistance, and does not fully reflect the perfusion of the kidney, brain or gastrointestinal tract.
6. Continuous monitoring of vital signs and hemodynamics.
(II) Supplemental blood volume
It is the key to correct shock-induced tissue hypoperfusion and hypoxia. It is advisable to follow the basic principles of “fast first, then slow, salt first, then sugar, crystal first, then colloid, and potassium supplementation in urine”. On the basis of continuous monitoring of arterial blood pressure, urine volume and CVP, the effect of blood volume supplementation should be judged by combining the patient’s skin temperature, peripheral circulation, pulse amplitude and capillary filling time and other microcirculatory conditions. In case of combined hemorrhagic anemia, we should actively contact blood sources for transfusion of red blood cells, fresh frozen plasma for those with poor coagulation function, and platelets for those with significant platelet reduction.
Traumatic shock currently advocates the adoption of restrictive fluid resuscitation in an effort to minimize the damage. It is the prudent implementation of hypotensive measures to reduce internal bleeding before applying surgical control of bleeding. The aim is to seek a balance point of resuscitation that can appropriately restore blood perfusion to tissues and organs without disrupting the compensatory mechanisms and internal environment of the organism too much. Studies have shown that routine rehydration before complete hemostasis can cause an increase in blood pressure, thus aggravating bleeding; at the same time, excessive blood dilution may dislodge the clot that has been formed and is not conducive to the formation of new clots, thus reducing the coagulation function of the body and triggering rebleeding; excessive transfusion may also cause pulmonary edema and interstitial pulmonary edema, which is not conducive to oxygen diffusion; excessive blood dilution decreases hematocrit, which is not conducive to oxygen The excessive dilution of hematocrit is not conducive to oxygen carriage and transport, etc. Therefore, thorough surgical hemostasis should be actively performed to reduce and shorten the degree and duration of shock, so that the body can return to its pre-injury physiological state as soon as possible. After complete hemostasis, if the shock cannot be corrected due to insufficient volume, rapid rehydration is still possible.
(C) actively deal with the original disease
Shock caused by surgical disease should be promptly carried out on the basis of restoring the effective circulating blood volume as soon as possible and timely surgical treatment of the primary lesion. For example, control of visceral haemorrhage, resection of necrotic intestinal collaterals, repair of gastrointestinal perforation and drainage of pus, etc.
(iv) Correction of acid-base imbalance
Premature use of alkaline drugs is not advocated. Mild acidosis can often resolve on its own after the correction of shock. However, when severe shock combined with acidosis is not treated satisfactorily by volume expansion, it is still necessary to use alkaline drugs. It is necessary to ensure normal respiratory function before administration to avoid carbon dioxide retention and secondary respiratory acidosis.
Metabolic acidosis usually only needs to reduce or eliminate the cause, for example, the acid that has accumulated, such as lactic acid, can be converted into HCO3, and thus the acidosis can be relieved by itself. If pH <7.2, 5% sodium bicarbonate 100ml IV drip is often used. pH <7.1 should be brought back to above 7.1 as soon as possible. However, it should not be raised rapidly and the aim of treatment is to adjust, not to correct.
Metabolic alkalosis is often accompanied by hypokalemia, and attention should be paid to potassium supplementation. It is advisable to give potassium chloride rather than potassium citrate, which increases HCO3.
Respiratory acidosis is mostly due to inadequate ventilation and must be accompanied by hypoxia. In cases of upper airway obstruction, the airway can often be improved by tracheal intubation, incision, and suctioning to ensure the airway is open and oxygen is given at the same time. As for those with pulmonary lesions and small airway obstruction, they are not easily relieved and should be prevented and treated in multiple ways to be effective.
Respiratory alkalosis is caused by hyperventilation, which can be relieved by eliminating the cause and not making hyperventilation. Using mask oxygen or paper tube can increase the reabsorption of exhaled carbon dioxide, which is beneficial to the recovery of respiratory alkalosis.
(E) Application of vasoactive drugs
Vasoactive drugs cannot replace volume resuscitation, and should only be applied when the condition is critical and blood pressure cannot be maintained after volume resuscitation. Clinically, the application of vasoactive drugs should be started from small doses and adjusted according to the actual effect, which can be gradually increased and gradually reduced when the drug is discontinued. In practice, they should be used in combination to complement each other’s strengths and weaknesses. The use of vasoconstrictors to raise blood pressure and vasodilators to increase tissue perfusion, in order to obtain better therapeutic results.
1.Vasoconstrictor
Dopamine is the most commonly used vasoconstrictor, with excitatory effects on α, β and dopamine receptors, and its pharmacological effects are dose-related. Small dose (less than 5ug/min.kg) mainly for the alpha receptor effect, increase peripheral vascular resistance. Its cardiotonic and visceral vasodilatory effects are mainly taken in anti-shock. Small doses of dobutamine are often taken in combination with other vasoconstrictive drugs, also with norepinephrine, m-hydroxylamine, etc. Dobutamine has a strong contractile effect on the myocardium, easily inducing arrhythmias, and should not be used in cardiogenic shock.
2.Vasodilator
The early stage of shock is mainly manifested as pre-capillary microvascular spasm, and the later stage is dominated by micro-venous and small venous spasm. Therefore, shock should be selected according to the specific condition of vasoactive drugs, in order to take into account the perfusion level of the important organs, often combined application of vasoconstrictors and dilators. The commonly used vasodilator is the anticholinergic drug scopolamine (synthetic product 654-2), which has a good cell membrane stabilization effect and can counteract smooth muscle spasm caused by acetylcholine and make vasodilation, thus improving microcirculation. Atropine, sodium nitroprusside or the receptor blockers phentolamine and phenazopyridine can also be used.
3.Cardiac stimulants
Cardiac glycosides can enhance myocardial contractility and slow down heart rate. Cetiran 0.2mg intravenous injection is commonly used, repeated every 2-4h if necessary, the maximum daily dose does not exceed 1.6mg, pay attention to prevent drug overdose poisoning. Drugs including excitatory alpha and beta adrenergic receptors with cardiotonic function, such as dobutamine and dobutamine, can also be used.
4.Treat DIC and improve microcirculation
For diagnosed DIC, heparin sodium or low molecular heparin calcium can be used for anticoagulation. Anti-fibrinolytic drugs such as aminomethylbenzoic acid, aminohexanoic acid, aspirin, pentoxifylline and small molecule dextran can also be used for anti-platelet adhesion and aggregation.
5.Corticosteroids
Corticosteroids can be used for infectious shock, anaphylaxis and other more severe shock. Intravenous high-dose shock therapy is often used. The main mechanism of action is:
(1) Blocking the excitatory effect of alpha-receptors, causing vasodilation, reducing peripheral vascular resistance and improving microcirculation;
(2) Protect intracellular lysosomes and prevent lysosomal rupture;
(3) Enhance myocardial contractility and increase cardiac output;
(4) Promote mitochondrial function and prevent leukocyte agglutination;
(5) Promote gluconeogenesis, convert lactic acid into glucose and reduce acidosis.
6.Other drugs
(1) Calcium channel blockers: such as verapamil, nifedipine and diltiazem, etc., have the effect of preventing calcium ion inward flow and protecting cell structure and function.
(2) Morphine-like antagonists: naloxone, which can improve tissue blood perfusion and prevent cellular dysfunction.
(3) Oxygen radical scavengers: such as superoxide dismutase, which can reduce the damaging effect of oxygen radicals on tissues in ischemia-reperfusion injury.
(4) Regulation of prostaglandins in vivo: such as infusion of prostacyclin to improve microcirculation.
(5) adenosine triphosphate, magnesium chloride therapy: has the effect of increasing intracellular energy, restoring the role of cell membrane sodium C potassium pump and preventing cell swelling and restoring cell function.
(6) Prevention of complications
When rescuing traumatic shock casualties, corresponding measures should be taken to prevent the occurrence of complications (such as crush syndrome, gap syndrome, DVT, ALI, ARDS, MODS, MOF, DIC, etc.) to avoid further damage to the organism.